不同麻醉方法对骨科老年患者血管性血友病因子、纤维蛋白原、凝血酶抗凝血酶复合物和D-二聚体的影响

Effects of different anesthetic methods on von Willebrand factor,fibrinogen,thrombin-antithrombin complex and D-dimer in senile patients undergoing orthopaedic surgery

目的探讨不同麻醉方法对骨科老年患者血管性血友病因子(vWF)、纤维蛋白原(FIB)、凝血酶抗凝血酶复合物(TAT)和D-二聚体的影响。方法选择择期行髋部以下骨科手术的老年患者60例,随机分入硬脊膜外腔阻滞麻醉组(硬脊膜组)、硬脊膜外腔阻滞加全身麻醉组(联合组)和全身麻醉组,每组20例。所有患者均分别于麻醉前或麻醉诱导前(T1)、麻醉完善后或麻醉诱导后(T2)、术毕即刻(T3)、术后24h(T4)和术后48h(T5)5个时间点采集动脉血,测定vWF、FIB、TAT和D-二聚体水平,并记录麻醉时间、手术时间、术中出血量、输血量和输液量。结果硬脊膜组在T2、T3时间点的vWF水平均显著低于同组T1时间点(P值均<0.01),联合组在T3时间点的vWF水平显著低于同组T1时间点(P<0.05),硬脊膜组和联合组在T2、T3时间点的vWF水平均显著低于全身麻醉组同时间点(P值分别<0.01、0.05)。硬脊膜组和联合组在T2、T3时间点的FIB水平均显著低于同组T1时间点(P值均<0.01),硬脊膜组、联合组和全身麻醉组在T4、T5时间点的FIB水平均显著高于同组T1时间点(P值分别<0.05、0.01),硬脊膜组在T2、T3、T4时间点和联合组在T3、T4时间点的FIB水平均显著低于全身麻醉组同时间点(P值分别<0.05、0.01)。硬脊膜组、联合组和全身麻醉组在T4、T5时间点的TAT水平均显著高于同组T1时间点(P值均<0.05),硬脊膜组和联合组在T3时间点的TAT水平均显著低于全身麻醉组同时间点(P值分别<0.05、0.01)。全身麻醉组T3时间点的D-二聚体水平显著高于同组T1时间点(P<0.05)。3组间麻醉时间、手术时间、术中出血量、输血量和输液量的差异均无统计学意义(P值均>0.05)。结论硬脊膜外腔阻滞麻醉和硬脊膜外腔阻滞加全身麻醉可改善老年患者行髋部以下骨科手术时的高凝血状态,有助于预防围术期心脑血管病的发生和下肢深静脉血栓的形成,是老年患者行骨科手术时可选择的适宜的麻醉方法。

Objective To study the influence of different anesthetic methods on yon Willebrand factor （vWF）, fibrinogen （FIB）, thrombin-antithrombin complex （TAT） and D-dimer in elderly patients receiving orthopedic surgery. Methods Sixty senile patients scheduled receiving orthopedic surgery below hip were randomized to undergo epidural anesthesia （epidural group）, epidural anesthesia plus general anesthesia （combined group） and general anesthesia （general group）, with 20 patients in each group. Arterial blood was collected before anesthesia （T1）, immediately after induction of anesthesia （T2）, immediately after surgery （T3）, 24 h after surgery （T4）, and 48 h after surgery （T5）. The concentrations of vWF, FIB, TAT and D-dimer were examined. The duration of anesthesia, surgical time, intraoperative blood loss, blood transfusion and fluid replacement were recorded. Results Compared with T1, the concentrations of vWF at T2 and T3 were significantly decreased in epidural group （both P〈0. 01）; the concentration of vWF at T3 was also significantly decreased in the combined group （ P〈0.05）. Compared with those in general group, the concentrations of vWF at T2 and T3 were significantly decreased in epidural group and combined group （ P〈0.05 or 0.01 ）. Compared with T1, the concentrations of FIB at T2 and T3 were significantly decreased in epidural group and combined group （all P〈0.01 ） ; however, the concentrations of FIB at T4 and T5 were significantly elevated in all three groups （P〈0.05 or 0.01 ）. The concentrations of FIB at T2, T3 and T4 in epidural group and at T3 and T4 in combined group were significantly lower than that in general group （ P〈0.05 or 〈0.01 ）. Compared with that at T1, the concentrations of TAT at T4 and Ts were significantly elevated in all three groups （all P〈0.05）. The concentrations of TAT at T3 in epidural group and combined group were significantly lower than that in general group （P〈0.05 or 〈0.01）. Compared with that at T~, the concentration of D-dimer at T3 was significantly elevated in general group （P〈0.05）. There were no significant differences in terms of the duration of anesthesia, surgical time, intraoperative blood loss, blood transfusion or fluid replacement （all P〉0.05）. Conclusion Both epidural anesthesia and general anesthesia combined with epidural block are suitable for senile patients undergoing orthopedic surgery below hip joint. They both can improve perioperative hypercoagulabale state, help to prevent perioperative cardiovascular and cerebrovascular diseases and deep venous thrombosis of lower extremity. （Shanghai Mad J, 2014, 37= 673-677）